Hierarchy
BBPCRM (Software Component) BBPCRM⤷
CRM (Application Component) Customer Relationship Management⤷
CRM_APPLICATION (Package) All CRM Components Without Special Structure Packages⤷
NBAS (Package) Appl. development Hospital System master data, catalogs
IMG Activity
| ID | ISH_SG_CONTRACT_CAT | SG,CH, CA: Maintain Contract Schemes |
| Transaction Code | S_KK4_74000363 | IMG Activity: ISH_SG_CONTRACT_CAT |
| Created on | 19990816 | |
| Customizing Attributes | ISH_SG_CONTRACT_CAT | SG,CH, CA: Maintain Contract Schemes |
| Customizing Activity | ISH_SG_CONTRACT_CAT | SG,CH: Maintain Contract Schemes |
Document
| Document Class | SIMG | Hypertext: Object Class - Class to which a document belongs. |
| Document Name | ISH_SG_CONTRACT_CAT |
Contract schemes let you qualify the insurance information pertaining to an insurance relationship for a case. You can specify different contract schemes for each institution. Contract schemes are independent of insurance providers and insurance provider types.
The information contained in the contract schemes is stored on two levels:
- The header data contains general information that is relevant for the contract scheme as a whole.
- The item data contains information at service or service group level.
Header Data
The following fields are available to you here:
- Validity Period
The validity period (Valid From and Valid To fields) determines the validity of the contract scheme. You can only assign a contract scheme to an insurance relationship if the insurance relationship and the contract scheme have a common validity period. - Currency
In this field, you stipulate the currency for all amounts in the contract scheme. If you do not make an explicit specification, the system fills the field with the local currency of the institution. - Max. Days/Year
Here you stipulate for how many days in the year the contract scheme is to be valid for an inpatient case. The system uses this specification as the maximum value for this contract scheme in the payment distribution function. The specifications relate to a calendar year.If the system is to take into account days already covered from a previous case of the patient, enter the number of days in the Previous Days field when maintaining the insurance relationship.
This field is taken into account for inpatient cases only.
Example:
You enter the value 8 in the Max. Days/Year field of the contract scheme.
The system takes into account no more than the first 8 days of the hospitalization for this contract scheme.
Service charges incurred after this time must be borne by other insurance providers.
If you also specify the value 5 in the Previous Days field , the system only takes into account the first 3 days for this contract scheme.
- Compensation Service and Service catalog
In the country version Switzerland , you can specify a compensation service in these fields.
With compensation, the insurance provider covers the amounts specified in the contract scheme irrespective of the prices of the services that are actually performed.
If the total amount of the relevant services is less than the amount the insurance provider has agreed to cover, the compensation service specified here is valuated with this difference. The compensation service is then assigned to be covered by this insurance provider. The compensation service is generated in relation to the billing agreement. This means that a corresponding billing agreement must exist for each insurance provider for which compensation is allowed.
Example:
The contract scheme specifies that the insurance provider covers CHF 30.- for all laboratory services. The compensation service COMPENSATION is defined in the system.
Laboratory services for a value of CHF 20.- are now performed for a case (with corresponding insurance provider and contract scheme). This means that the COMPENSATION service is valuated with the price CHF 10.- and is assigned along with the laboratory services for coverage by the insurance provider.
- Case Type
In this field, you can specify for which type of case your contract scheme is to be valid. - Interim Billing
Select Interim Bill. if interim billing is allowed with the contract scheme. This field is only evaluated for outpatient cases. - Ext. FM and Destination
Here you can specify a function module and an RFC destination.
When payment distribution is performed, the system evaluates the function module specified in the Ext. FM field and not the header and item structure.
In this function module you can tailor payment distribution to meet your specific requirements.
The interface of this function module is predefined. For more information, refer to the documentation on contract schemes for external processing.
- Percent, Max./Case and Max.Day/Visit
Using these fields, you can limit the maximum amount covered by an insurance relationship.
The fields Percent and Max./Case relate to the complete case. If you make an entry in both fields, the lower of the two amounts is relevant for payment distribution.
With regard to the Max.Day/Visit field, you can also specify whether the valuation is to be made per day/visit or for the whole case.
If you select Overall Valuat., the system multiplies the amount in the Max.Day/Visit field by the number of days the patient spends in your healthcare facility or by the number of visits to produce the maximum amount for the case.
If you select the Valuation per Day field, the system re-evaluates the maximum amount for each single day/visit.
Example:
A patient spends 3 days in your healthcare facility. The following costs are incurred during this period:
Day 1: 100.-
Day 2: 200.-
Day 3: 50.-
The particular contract scheme assigned limits the insurance coverage to 100.- per day.
If you selected Overall Valuat., the insurance covers 300.- for the complete stay (100.- for each of the three days). However, if you selected Valuation per Day, the insurance covers only 250.- in total. The costs incurred per day are compared with the Max./Case.
Day Costs Costs Covered by Insurance
1 100.- 100.-
2 200.- 100.-
3 50.- 50.-
- Restrictions for Contract Schemes
The enhancement NPDIST00 lets you specify a requirement governing the use of the contract scheme in a function exit. The system evaluates this requirement when carrying out payment distribution. If the requirement is met, the contract scheme is evaluated. In the contrary case, the processing of the current insurance relationship is terminated. No payments are assigned to the insurance relationship.
Please read the documentation on the enhancement NPDIST00 and on the function exit EXIT_SAPLNPD1_001.
Item Data
The items contain restrictions at service level. Here you can make specifications relative to the coverage of single services or groups of services:
- Rank
You have to specify a rank for each item. This rank determines the processing sequence for payment distribution.
- Movement Type
Enter a movement type for which the item is to be valid.
- If the contract scheme is evaluated for an inpatient case, the system only evaluates the item if the admission type of the case is identical to the movement type specified in this field.
- If the contract scheme is evaluated for an outpatient case, only those services that are assigned to a visit of a type identical to the movement type specified in this field are taken into account for the item. However, if you have set the system parameter Outp. Billing: Billing with Visit Type of 1st Visit (AMB_BESF), the system always uses the visit type of the first outpatient visit for all of the services of an outpatient case.
- Percent, Max./Case and Max.Day/Visit
Just as in the header data, here you can make specifications relative to the maximum coverage. However, in the item data these values refer to specific services only (see below).
- To-Day
This field is available in the country version Switzerland only.
In this field, enter the date to which the item is to be valid. The item must refer to exactly one extended service here. An entry is not possible for service groups or immediate services.
By defining several items with the same service but with a different entry in the To-day field, you can create a daily scale for the coverage of this concrete service.
The day specifications always relate to the days in which the corresponding service was performed.
Example:
- Item 1, To-day: 5, Service: XYZ, Max/Case: 30.-
- Item 2, To-day: 8, Service: XYZ, Max/Case: 20.-
- Item 3, To-day 12, Service: XYZ, Max/Case: 10.-
From the 1st to the 5th day on wh
Business Attributes
| ASAP Roadmap ID | 203 | Establish Master Data |
| Mandatory / Optional | 2 | Optional activity |
| Critical / Non-Critical | 2 | Non-critical |
| Country-Dependency | I | Valid for countries specified |
| Customizing Attributes | Country Key | Country Name |
|---|---|---|
| ISH_SG_CONTRACT_CAT | CA | Canada |
| ISH_SG_CONTRACT_CAT | CH | Switzerland |
| ISH_SG_CONTRACT_CAT | SG | Singapore |
Assigned Application Components
| Documentation Object Class | Documentation Object Name | Current line number | Application Component | Application Component Name |
|---|---|---|---|---|
| SIMG | ISH_SG_CONTRACT_CAT | 0 | I010004204 | Patient Accounting |
Maintenance Objects
| Maintenance object type | C | Customizing Object |
| Assigned objects | ||||||
|---|---|---|---|---|---|---|
| Customizing Object | Object Type | Transaction Code | Sub-object | Do not Summarize | Skip Subset Dialog Box | Description for multiple selections |
| C_TN16 | C - View cluster | SM34 | 0000000001 | Maintain Contract Schemes |
History
| Last changed by/on | SAP | 20020322 |
| SAP Release Created in |
